John Marcille

John Marcille

There is no such thing as an unqualified success in this life, and even our cover story, which examines the amazing turnaround at the Veterans Health Administration, concedes that this government system is not perfect. The problems that it has, however, remind me of the stories at the turn of this decade fretting over what to do about huge national budget surpluses.

We should have such problems now. At some point, we are going to have to tighten our belts, and the VHA offers a case study in getting the biggest bang for the buck. The need for belt-tightening goes not only for the federal budget; it applies all the way down the line. Admittedly, there are things that can be done in a nearly closed, hospital-based system for a clearly defined population that cannot be replicated by commercial health plans in the fractious open market. But one of the promises of managed care has been that it can control costs. For a few years in the early to mid '90s, it appeared to be doing just that. It does not appear to be doing so now, but maybe someone will explain to me that it is making a valiant effort against irresistible pressures.

The VHA turnaround happened to a great extent because of the man on our cover, Kenneth Kizer. There are probably many theories about what moves history along. There's the "great man" theory. Today's historians are more likely to say that history is shaped by societal pressures that move across space and time like an amoeba oozing under a microscope, with some help from physical phenomena like plagues and — just guessing here — global warming.

Both views of history, I suppose, have merit, and they are not necessarily exclusive, at least within microcosms (a century, a nation).

Not everyone thinks Ken Kizer was a totally positive force at the VHA, but man, did he get results.

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.